JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

VOL. 64, NO. 20, 2014

ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

ISSN 0735-1097/$36.00

PUBLISHED BY ELSEVIER INC.

http://dx.doi.org/10.1016/j.jacc.2014.08.027

CONFERENCE REPORT

Protecting the Heart of the American Athlete Proceedings of the American College of Cardiology Sports and Exercise Cardiology Think Tank October 18, 2012, Washington, DC

Writing

Christine E. Lawless, MD, FACC, FACSM

Mark S. Link, MD, FACC

Committee

Chad Asplund, MD, FACSM

Matthew W. Martinez, MD, FACC

Members

Irfan M. Asif, MD

G. Paul Matherne, MD, FACC

Ron Courson, ATC, PT

Brian Olshansky, MD, FACC

Michael S. Emery, MD, FACC

William O. Roberts, MD, MS, FACSM

Anthon Fuisz, MD, FACC

Lisa Salberg

Richard J. Kovacs, MD, FACC

Victoria L. Vetter, MD, MPH, FACC

Silvana M. Lawrence, MD, PHD, FACC

Robert A. Vogel, MD, FACC

Benjamin D. Levine, MD, FACC, FACSM

Jim Whitehead

Yvette L. Rooks, MD, CAQ, FAAFP1

Mark Link, MD, FACC19

Conference Participants

G. Paul Matherne, MD, FACC Jim Whitehead Dan Henkel

2

Lisa Salberg20

3

Chance Gibson21

3

Mary Baker RN, MSN, MHA22

Irfan M. Asif, MD

4

Andrea Daniels, MSN23 5

Richard J. Kovacs, MD, FACC24

James C. Dreese, MD Rory B. Weiner, MD

6

Michael French, MD25

Barbara A. Hutchinson, MD, PHD, FACC Linda Tavares, MS, RN, AACC Steven Krueger, MD, FACC Mary Jo Gordon Joan Dorn, PHD

7

8

Matthew W. Martinez, MD, FACC26

9

Bryan W. Smith, MD, PHD27

10

Christine Lawless, MD, FACC, FACSM28

11

Hilary M. Hansen

Feleica G. Stewart25

Aaron Baggish, MD29 12

Ron Courson, ATC, PT, NREMT, CSCS30

Victoria L. Vetter, MD, MPH, FACC Nina Radford, MD

13

David Klossner, PHD, ATC31

14

Dennis Cryer, MD, FACC

William M. Heinz, MD32 15

Andrew Tucker, MD33

Chad Asplund, MD, FACSM Michael Emery, MD, FACC

16

Robert A. Vogel, MD, FACC34

17

Paul D. Thompson, MD, FACC, FACSM

Susan Shurin, MD35 18

Anthony Colucci, DO, FACEP36

The findings and conclusions in this report are those of the conference participants and do not necessarily reflect the official position of the American College of Cardiology. Indiana University Health provided unrestricted educational grants for this meeting. The American College of Cardiology requests that this document be cited as follows: Lawless CE, Asplund C, Asif IM, Courson R, Emery MS, Fuisz A, Kovacs RJ, Lawrence SM, Levine BD, Link MS, Martinez MW, Matherne GP, Olshanksy B, Roberts WO, Salberg L, Vetter VL, Vogel RA, Whitehead J. Protecting the heart of the American athlete: proceedings of the American College of Cardiology Sports and Exercise Cardiology Think Tank, October 18, 2012. J Am Coll Cardiol 2014;64:2146–71. Permissions: Multiple copies, modifications, alterations, enhancement, and/or distribution of this document are not permitted without the express permission of the American College of Cardiology. Please contact Elsevier’s Permission Department at [email protected] to obtain permission for any of these uses of the document.

Lawless et al.

JACC VOL. 64, NO. 20, 2014 NOVEMBER 18/25, 2014:2146–71

Protecting the Heart of the American Athlete

Michele Snyder37

Health System.

Cathy Rabb, RRT, RCP, MHA Anthon Fuisz, MD, FACC

CARE Foundation. 11Centers for Disease Control Children’s Cardiomyopathy Foundation, Inc..

The Children’s Hospital of Philadelphia.

15

Cryer Health.

Alfred Bove, MD, PHD, MACC40

16

14

Cooper Clinic.

Eisenhower Army Medical Center. 17Greenville

Health System, University of South Carolina School of Medicine-

Silvana Lawrence, MD, PHD, FACC41

Greenville.

18

Hartford Hospital.

American Heart Association.

42

21

Association.

Curt Daniels, MD, FACC43

23

Brian Olshansky, MD, FACC44 45

25

29

Renee Sullivan, MD46 Benjamin D. Levine, MD, FACC, FACSM

27

Network.

Heart Rhythm Society and

Hypertrophic Cardiomyopathy

24

Massachusetts General Hospital. 31

Indiana University Health. 26

John Stewart Foundation. 28 30

Lehigh Valley Health

Major League Soccer.

National Athletic Trainers’

National Collegiate Athletics Association.

Federation of State High School Associations. League.

34

National Football League.

Blood Institute. 38

2

American Academy of Family Physicians. American

36

Medicine. 4American Medical Society for Sports

School.

41

32

National

National Football

37

Parent Heart Watch.

40

39

Society for

Temple University Medical

Texas Children’s Hospital and Baylor College of 42

Medicine. American Orthopaedic Society for Sports

Medicine.

Medicine. 6American Society of Echocardiography.

Heart Center.

7

45

Association of Black Cardiologists. 8Bon Secours

33

National Heart, Lung and

Presbyterian Medical Center-Novant Health.

Cardiovascular Magnetic Resonance.

5

35

National Hockey League.

Academy of Pediatrics. 3American College of Sports

The Coca-Cola Company. 44

43

The Ohio State University

University of Iowa Hospitals and Clinics.

University of Minnesota.

46

University of Missouri.

47

University

of Texas Southwestern Medical Center.

Virginia Heart & Vascular Institute. 9Bryan LGH

ABSTRACT

22

Indiana University School of

Major League Baseball.

Association.

47

19

20

IM Strategic Partners.

Indiana University Health.

Medicine.

William O. Roberts, MD, MS, FACSM

1

12

13

39

Maxime Buyckx, MD, MBA

10

and Prevention.

38

in the optimal use of existing clinical athlete cardiovascular care tools; 3) Promoting and conducting research

Despite the documented health benefits of physical exercise, there is a paradoxical, but small, risk of sudden cardiac arrest (SCA) and/or death (SCD) associated with exercise. Cardiovascular causes account for 75% of sportrelated deaths in young athletes, with SCA/SCD rates varying according to athlete age, gender, intensity of ac-

to define normative values for cardiac tests in large numbers of American athletes and developing datadriven management algorithms; and 4) Coordinating athlete advocacy efforts by creating athlete cardiovascular care state-wide task forces. The Think Tank plans to convene every 2 years to monitor progress.

tivity, race, and ethnicity. True risk for American athletes is difficult to assess owing to the lack of a national registry with well-defined numerators and denominators, and a

INTRODUCTION

consensus on metrics. Although exercise-related syncope and/or chest pain are considered the most ominous pro-

Regular physical activity confers numerous health bene-

dromal complaints, the true predictive value of symptoms

fits for individuals of all ages (1–5). Current United States

is not known in athletic populations. The comparative

physical activity guidelines recommend that healthy

effectiveness of various screening methodologies (e.g.

adults accumulate 2.5 hours of moderate activity per

history and physical alone versus history and physical

week and children accumulate at least 60 minutes of daily

plus electrocardiogram) with regard to athlete outcomes

physical activity, with 20-30 minutes of vigorous activity

has not been determined. To address these issues in

3 days per week for both age groups (6). Although these

American athletes, and to coordinate a nation-wide

recommendations have resulted in record numbers of

multidisciplinary approach to athlete cardiovascular

Americans participating in sports and exercise in all major

care, the American College of Cardiology Sports and Ex-

demographic groups (7–9), the vast majority of the U.S.

ercise Cardiology Section convened the “Think Tank to

population is sedentary (10).

Protect the Heart of the American Athlete and Exercising

Despite the benefits of physical exercise, there is a

Individual” on October 18, 2012, in Washington, DC. Think

paradoxical, but small, risk of sudden cardiac arrest (SCA)

Tank participants (representing athletic trainers; primary

and/or death (SCD) associated with exercise (11). Attempts

care professional societies; cardiovascular specialty, sub-

to reduce the incidence of SCA/SCD by adding resting

specialty, and imaging societies; government agencies;

electrocardiograms (ECG) to athlete pre-participation

industry; sports governing bodies; and patient advocacy

evaluation (PPE) in the United States have led to robust

groups) identified 92 quality gaps, and created an action

debate

plan to address the most urgent of these gaps: 1) Defining

screening strategies with regard to outcomes (12,13). This

sports cardiology outcome metrics and conducting high-

debate has contributed to the growing discipline of sports

quality epidemiologic research; 2) Educating providers

and exercise cardiology in the United States, and to the

regarding

the

comparative

effectiveness

of

2147

2148

Lawless et al.

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Protecting the Heart of the American Athlete

expanding role of the cardiologist as a member of the

programs, which is more easily applied to high school,

athlete healthcare team (14).

college, professional teams, and masters athletes but ex-

Numerous multidisciplinary groups are addressing

cludes those who are involved in high-level physical ac-

athlete cardiovascular care issues with the goal of

tivity away from competition or in organized groups (15).

improving athlete safety (14–19). Several states have

In reality, American athletes come in all ages and sizes

introduced or passed SCA/SCD-related legislation to

with differing cardiac demands and adaptations to sport

regulate

automated

depending on the combination of static and dynamic

external defibrillators (AEDs) in all schools; and/or

components of the activity (15,16). For the purposes of this

athlete

PPE

screening;

require

educate parents, students, coaches and athletic staff

document, we define the American athlete as any individual

regarding risk, symptoms, and treatment (20,21). Patient

who engages in routine vigorous physical exercise in the

advocacy groups are promoting awareness of SCA/SCD

settings of competition, recreation, or occupation (14).

causes and consequences in children, adolescents, and young adults (22–24), and federal funding agencies (the

Participation

National Institutes of Health and Center for Disease

Sports participation can begin by age 4 to 6 years and

Control and Prevention) have reviewed the subject with

continue through masters competitions in the later

expert panels (25).

decades of life. Over 35 million U.S. youth aged 5 to 18

The American College of Cardiology (ACC) Sports and

years (52% of girls and 62% of boys) participate in orga-

Exercise Cardiology Section convened the “Think Tank to

nized team and individual sports in scholastic (40%) and

Protect the Heart of the American Athlete and Exercising

non-scholastic (60%) settings (27). Within this group,

Individual” on October 18, 2012, in Washington, DC. Its

approximately 7.7 million boys and girls participated in

purpose was to bring together a broad range of stake-

varsity program U.S. high school sports seasons in the

holders who provide cardiovascular care to American

2011-12 academic year (27). Over 450,000 student-

athletes, to identify quality gaps in existing care, and to

athletes participate in organized sports at the collegiate

create specific, multidisciplinary solutions to improve

level in the United States (28). These numbers do not

care. “Think Tank” participants represented athletic

include youth athletes and young adults participating

trainers; primary care professional societies; cardiovas-

in “off the grid” activities such as backcountry skiing,

cular specialty, subspecialty, and imaging societies; gov-

snowboarding, surfing, mountaineering, cycling, and

ernment agencies; industry; sports governing bodies; and

BMX biking. In addition, the number of middle-aged

patient advocacy groups. Through interactive discussions

and older adults participating in organized sports is

regarding risks to athletes, the meaning of symptoms, and

growing. Running USA tracks road race participation

primary and secondary prevention of SCA/SCD in ath-

and found there were nearly 14 million finishers (55% of

letes, the work group identified 92 quality gaps in four

them women) in 2011, up from 5.2 million in 1991 (29),

major domains: 1) Quantifying risks to American athletes;

and that the number of marathoner finishers over age

2) Education, and optimal use of existing clinical athlete

55 more than doubled (from 32,500 to 76,500) between

care tools; 3) Research, quality, and science; and 4)

1992 and 2008 (29).

Advocacy and communications. Once these gaps were identified,

Think

Tank

organizers

prioritized

gaps

depending on their level of urgency and, over the next

Cardiac Development and Adaptation Although somatotype (e.g., football linemen versus dis-

year and a half, continued their dialogue, incorporated

tance runners) may influence sport selection, cardiac ad-

most recent research, and compiled their recommenda-

aptations

tions. This report summarizes the findings of the Think

demands of the activity. Dynamic exercise substantially

Tank participants and authors, providing a practical ac-

increases maximum oxygen consumption, cardiac output,

tion plan to optimize American athlete cardiovascular

stroke volume, and systolic blood pressure, with an

health.

associated decrease in peripheral vascular resistance. In

are

most

affected

by

the

cardiovascular

contrast, static exercise leads to increases in diastolic

SECTION 1. THE AMERICAN ATHLETE

blood pressure, peripheral vascular resistance, and heart

AND RISKS OF PARTICIPATION

rate. Long-term adaptations to endurance training lead to cardiac remodeling secondary to both volume flow and

There is no universally accepted definition of an athlete.

increased cardiac output, whereas strength-based exer-

Merriam Webster defines an athlete as “a person who is

cise causes a predominant pressure effect, with minimal

trained or skilled in exercises, sports, or games requiring

increase in cardiac output (15,30).

physical strength, agility, or stamina” (26). The ACCF 36th

The heart grows as a child grows in physical stature,

Bethesda Conference definition adds the concepts of

with accelerated cardiac growth through puberty (31). The

regular

heart is a muscle and responds to exercise loads with left

competition

against

others

and

organized

Lawless et al.

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Protecting the Heart of the American Athlete

ventricular hypertrophy. As is the case with skeletal

Risk of SCD

muscle, the heart muscle’s thickness can decrease with

SCD risk increases with physical activity intensity and is

detraining. Children can participate in physical training

greatest in sedentary individuals during exercise (38).

and show improvements in VO2 max, but changes are

Exercise-associated SCA/SCD is arbitrarily defined as

generally modest and are influenced by age, onset of

occurring during or within an hour of physical activity,

puberty, and type of training (32). Absolute VO 2max

and although exercise-related death is rare overall, 75% of

values (l/kg) also increase with growth to age 18 in boys

sport-related deaths in young athletes are from cardio-

and to age 14 in girls (33). Relative to adults, at any level

vascular causes (39). In athletes under 35 years of age,

of VO2 max, children have a higher heart rate and arte-

exercise-related SCA/SCD is usually associated with

riovenous oxygen extraction, and lower systolic and dia-

structural or electrical cardiac abnormalities, including

stolic blood pressure, stroke volume, cardiac output, and

cardiomyopathies, coronary artery anomalies, channelo-

anaerobic metabolism. Endurance aerobic training in

pathies, congenital heart defects, acquired myocarditis,

children can produce a 5% to 6% increase in peak VO2,

and genetic syndromes (39–43).

and with high training volume plus consistent intensity

It is likely that SCA/SCD risk varies with age, gender,

of >80% maximum heart rate, peak VO 2 can rise

intensity of activity, race, and ethnicity (Table 1). The true

8%-10% (34).

risk for U.S. athletes is difficult to assess because there is

Other adaptations to exercise include increased left

neither a national registry with well-defined numerators

ventricular diastolic volume, increased vagal tone, and

and denominators nor consensus on metrics. Should both

benign arrhythmias like sinus bradycardia, first-degree

resuscitated SCA and SCD be included in the numerator?

atrioventricular block, and incomplete right bundle

Should all athletes be included in both the numerator and

branch block. It has been speculated that long-term

the denominator, or only those performing sports or ac-

endurance activity (e.g., Nordic skiing) may lead to cell

tivity at the time of SCA/SCD? Athlete SCA/SCD can be

damage or cardiac disease (34a). Almost all studies

defined as an episode occurring during or within 1 hour

performed in middle-aged and older endurance athletes

of exercise (44,45). However, some investigators include

have observed a greater risk of atrial fibrillation for these

all athletes in a well-defined demographic in the rate

athletes than for non-athlete controls (35,35a). Interested

equation,

readers are referred to these excellent reviews on this

during sleep or exercise or while out with injury (42).

regardless

of

whether

SCA/SCD

occurred

subject (35,35a). Similarly, recent studies of athletes

Differences in methodology can produce conflicting re-

following intense endurance exercise have shown an

sults (Table 1); SCA/SCD rates may vary by as much as

acute increase in troponin and B-natriuretic peptide

50%-75%, depending on whether one uses only those

(BNP) levels (36). This acute myocardial damage could

athletes exercising at the time of SCA/SCD or all athletes

lead to subsequent fibrotic remodeling of the ventricular

in a defined demographic (42,45,46). Whereas the former

myocardium that may act as a substrate for fatal

measures the risk of exercise as a trigger, the latter may

arrhythmias (37). Given the complexities of the heart

measure the risk of being an athlete. Both may be valid,

response to exercise, it is clear that defining normative

given that exercise is a known trigger for SCA/SCD (38,39),

data for the wide range of American athletes participating

whereas training adaptations and chronic effects of ex-

in all types of sports is paramount.

ercise render the athlete heart a different substrate from

TABLE 1

Reported SCD Incidence in the American General Adolescent Population and in Young Athletes Includes Resuscitated SCA

Incidence of SCD per 100,000 Person- or Athlete-Years

Population

Reference #

General population (12-19 years of age)

Atkins, 114

Yes

6.37*

MSHSL athletes (12-19 years of age)

Roberts, 75

No

0.24†

MSHSL athletes (12-18 years of age)

Maron, 76

No

0.7‡

NCAA athletes (exercise-related)

Harmon, 42

No

1.37§ 2.28k

NCAA athletes

"

"

NCAA male athletes

"

"

3.02k

NCAA black athletes

"

"

5.65k

Male NCAA Division I basketball athletes

"

"

31.99k

*All SCD in adolescents: athlete, and non-athlete, and regardless of activity. †Includes only SCDs occurring during MSHSL-sponsored game or practice. ‡Includes SCDs occurring in all MSHSL-age athletes, regardless of activity level at time of SCD. §Includes only SCDs occurring during exertion in NCAA athletes. kIncludes all NCAA athlete SCDs, whether occurring during competition, practice, sleep, or when the athlete is off with injury. MSHSL indicates Minnesota State High School League; NCAA, National Collegiate Athletic Association; SCA, sudden cardiac arrest; SCD, sudden cardiac death.

2149

2150

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Protecting the Heart of the American Athlete

that of the non-athlete (14,30). The distribution of ethnic groups varies around the country, further confounding the risk equation. Risks should be determined for the varying athletic populations; and approaches to screening should be tailored on the basis of known risks.

TABLE 2

Reference Ranges Anatomy and Diagnostic Parameters Based on Age (Years) and Intensity

Child Adolescent Early High school*

5-11 12-14 15-18

Refining Athlete Age and Competition Classifications

College*

19-22

The explosion of organized sporting activities for children

Young adult

23-34

presents parents with a variety of activities to choose for

Middle age adult

their children, ranging from entry-level sports participa-

Aging adult

tion to year-round “travel teams” with training schedules and competitions that rival college sports. Youth leagues are usually classified by age and/or skill level; however,

35-64 65 and beyond

*Usual ages for U.S. and college athletes. U.S. eligibility for sports ranges from ages 11 through 19 and college athletes can range up to age 25 in ice hockey and older in football.

young adolescent physical maturation should be considered because not all 12 year olds are created equal. Some

65% with cardiac syncope, compared with 18% in those

children have focused sports-specific goals and begin

with vasovagal syncope (49). In a study of young Euro-

vigorous training regimens by age 10 or even younger. For

pean athletes, 6.2% of 7,568 athletes (mean age 16.2  2.4

children, the competitive level, age and size of partici-

years) reported having had at least one syncopal episode

pants, and training intensity all represent important var-

within the preceding 5 years (50). These episodes were

iables in determining safe participation from a risk:benefit

not related to exercise (86.7% of all episodes), occurred

perspective.

immediately after exercise (12.0%), or during exercise

For athlete evaluation, screening and diagnostic in-

(1.3%). Although syncope occurring during exercise was

terventions likely need athlete-specific norms and more

rare overall (0.08% of the whole study population), un-

refined age groups than “adult” and “child” to make

derlying cardiac pathology was found in 33% of those who

reasonable

cardiovascular

risk

decisions

regarding

experienced syncope during exercise (50). Similar data

participation. It is important that data specific to a

have not been obtained in large numbers of American

particular athlete age group, genetic predisposition, sex,

athletes.

or intensity level not be extrapolated to make policy de-

In another European study of 33 athletes (mean

cisions for other athlete groups (e.g., college data applied

age 21.4  3.2 years) referred for recurrent episodes of

to high school age athletes). Suggested age groupings that

exercise-related syncope (mean number of episodes be-

likely reflect both age and intensity for the majority of the

fore evaluation was 4.66  1.97), 12.1% developed hypo-

population are listed in Table 2.

tension associated with pre-syncope during maximal exercise testing, and 22 subjects (66.6%) showed a posi-

SECTION 2. MEANING OF SYMPTOMS IN ATHLETES

tive response to head-up tilt testing (51). Underlying high-risk cardiac conditions were not present in this

Syncope and Collapse

group, but recurrence of syncope was common over the

The ultimate symptom of underlying heart disease is an

follow-up period. All studies considered, the widely held

episode of SCA/SCD. Studies of youth who have experi-

belief that syncope during exercise is more likely to be of

enced SCA/SCD find that approximately 50% reported

cardiac cause appears to be true. However, recurrent

antecedent symptoms (47). This can vary by condition. Of

episodes of exercise related-syncope appear to be asso-

those with long QT syndrome, 10%-30% present with

ciated with a more benign course. Associated chest pain

SCA/SCD as a first symptom (48). Syncope and collapse

or discomfort should be considered an ominous sign.

are among the most troublesome problems and yet, no

Older studies in non-athletic populations suggest that

consensus or evidence-based management approach ex-

experiencing fewer than 2 syncopal episodes or a

ists for athletes, and epidemiological data in this group

warning #5 seconds is more predictive of syncope due to

are scant.

ventricular rhythm or atrioventricular block than to syn-

Risk may depend upon the setting in which syncope

cope arising from other causes. In contrast, prodromal

occurs. As a general observation, syncope or collapse that

palpitations, blurred vision, nausea, warmth, diaphoresis,

occurs during or prior to completion of an event is more

lightheadedness, and warning lasting >5 seconds are

likely to represent cardiac or other concerning etiologies,

more predictive of neurocardiogenic syncope (51a) than of

whereas collapse following an event, especially an

syncope due to other causes. Similar data has not yet been

endurance event, may represent a more benign etiology.

generated in athletic populations.

American

In the sports medicine literature, the term “exercise-

patients #18 years, symptoms occurred during activity in

associated collapse” (EAC) has been coined to describe

In

a

non-athletic

general

population

of

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Protecting the Heart of the American Athlete

episodes of collapse, but not necessarily syncope with

of CP, and suggested work-ups are listed in Table 3.

loss of consciousness (52–55). EAC is defined as acute loss

Exertional CP (e.g., angina) occurs in up to 30% of pa-

of voluntary muscular tone resulting in a fall to the

tients with hypertrophic cardiomyopathy (58) and is the

ground in athletes who are conscious but unable to stand

most common cause of SCD in young athletes. In some

or walk unaided as a result of light-headedness, faintness,

patients with hypertrophic cardiomyopathy, CP may be

and dizziness that occurs after completion of an exer-

atypical, occurring at rest or with meals (58). Aortic

tional event or stopping exercise. True syncope with loss

dissection causes acute CP and may be associated with

of consciousness can also occur in the setting of EAC, but

congenital bicuspid aortic valve disease, Marfan’s syn-

EAC is associated with a rapid return of consciousness in

drome, Ehlers-Danlos syndrome, cocaine abuse, and

the supine position and generally with a prolonged period

weightlifting (59). There is an exhaustive differential for

of weakness or fatigue. Although the mechanism(s) for

CP in athletes (57).

EAC are multifactorial, EAC is thought to be principally

Cardiac causes must be considered first (even if

the result of transient postural hypotension caused by

briefly) so as not to miss high-risk, potentially lethal

either lower extremity pooling of blood once the athlete

conditions. Once cardiac CP has been excluded, more

stops running and the resultant overwhelming of normal

common etiologies can be explored. Although a 12-lead

autonomic compensatory mechanisms, or an inappro-

ECG (15 lead in children/youth) should be performed

priate neurally mediated reflex (52–55). It has been

for any athlete with CP, even a “normal” ECG should be

demonstrated that collapse in marathon runners accounts

interpreted with caution. Beyond the ECG, echocardiog-

for 59% of finish area medical encounters and affects

raphy should be performed when cardiac CP is sus-

1.4% of finishers (56). Although EAC is common, cardiac

pected, and interpreted according to the athlete’s sport,

syncope is part of the differential diagnosis and must be

race, gender, age and body size. Studies looking at cau-

ruled out from the benign forms of EAC. Distinguishing

ses of CP in athletes are lacking; therefore, large-scale,

between syncope and EAC involves a long differential and

prospective epidemiologic studies are needed to define

the reader is referred to comprehensive reviews on this

the predictive value of CP in diagnosing underlying

topic (52–55).

cardiac disease in athletes.

Potential cardiac etiologies and suggested work ups are listed in Table 3. Although these etiologies constitute

Palpitations

most of the life-threatening causes of syncope and

Although palpitations are not one of the 12 AHA ele-

collapse, heat stroke should also be considered for

ments (16), exercise-related palpitations are included in

collapsed athletes with prolonged exposure to high tem-

history form questions in the 4th PPE monograph (60).

peratures and humidity. Unless the athlete passes out

The incidence in athletes varies, from 0.3% to 70%, with

during monitoring, results of testing are suspect and

palpitations from all causes being much less common in

thoughtful consideration is needed to determine the best

young, school-age athletes but more common in highly

approach and methodology to quantify risk and under-

trained and older athletes (61). The history should focus

stand the syncopal episode. The phrase “unknown syn-

on the timing of palpitations (day, night, while trying to

cope” is too vague, especially when considering return to

go to sleep, during exercise, before an event); presence

play and eligibility questions, and should be avoided.

of social stressors; supplement, alcohol, recreational

Depending on the severity and recurrence of episodes, an

drug, and caffeine intake; associated symptoms, partic-

appropriate approach to restricting the athlete’s activities

ularly syncope or near syncope (see Syncope section);

needs to be defined. For those who undergo treatment, a

a precise description of sensation, including sudden

follow-up plan based on sport and the clinical presenta-

onset and/or cessation; duration of symptoms; and any

tion and data-driven return-to-play guidelines need to be

family history of sudden death in relatives #50 years old

developed.

or inheritable cardiac disease. Differential diagnosis of cardiac causes of palpitations, and suggested work ups

Chest Discomfort

are listed in Table 3.

Among athletes 35 years has been re-

Advanced life support in the field increases the likelihood

ported at 1:1,000, suggesting that emergency preparations

of survival in cardiac arrest, and hospital care with

should extend beyond athlete participants (123,124).

induced hypothermia dramatically improves prognosis (111). The new AHA guidelines support the delivery of

Keys to Successful Resuscitation

high-quality

Emergency Action Plans

chest

compressions

with

minimal

in-

terruptions for both hands-only and conventional CPR.

The ability to respond to SCA depends heavily on prepa-

Factors including quality, depth, rate of compressions,

ration and a coordinated effort on the part of all re-

and duration of interruptions impact the outcome of the

sponders. In 2004, the AHA recommended that all schools

cardiac arrest (112).

have an emergency action plan (110,125). The 2007 InterAssociation Task Force provided consensus recommen-

Effectiveness of AED Programs

dations for the management of SCA in the athletic setting,

High School Athletics

which include the need for schools to have onsite AEDs if

SCA in young athletes is a catastrophic event with a his-

they cannot reliably achieve an EMS call-to-shock interval

torically low survival rate (4% to 21%) (113–115). Data from

of less than 5 minutes (17). Elements of an effective

486 cases of exercise-related SCA in young individuals

AED program include: 1) development of an effective

show an average survival rate of just 11% from 2000 to

communication system to alert onsite responders and

2006 (113). A similar survival rate of 16% was found in 128

activate the local EMS system; 2) coordination of the

cases from the USA Commotio Cordis Registry (116). These

response plan among school, team, or club staff and local

results are attributable to delayed rescuer recognition of

EMS; 3) instruction and training of potential first re-

SCA, slow response times, and inadequate preparation.

sponders in CPR and AED use; 4) rapid availability of AEDs;

Early CPR and defibrillation with an AED in youth can

and 5) practice and review of the EAP at least annually (125).

result in a survival rate of 64% to 74% (117). A 2-year

Steps also should be taken to ensure appropriate device

prospective study in 2,149 high schools indicated that

maintenance and readiness checks before sporting events.

87% of participating schools had an onsite AED program,

The EAP should be developed and coordinated with local

with 89% of students and adults who developed SCA

EMS personnel, school public safety officials, on-site first

during sports or physical activity at schools with an onsite

responders, and school administrators, and reviewed with

program surviving to hospital discharge (118). The sur-

certified athletic trainers, team and attending physicians,

vival rate for commotio cordis in young athletes has

athletic training students, school and institutional safety

increased to 58% in the last 6 years, largely because of

personnel, and coaches. EAPs should be specific to each

increased recognition, greater availability of AEDs, and

individual athletic venue. The first responder may be a

early defibrillation (119). Early defibrillation and onsite

coach, strength and conditioning staff, or other institu-

AED programs are therefore both critical and effective in

tional personnel. Involving student athletes in the EAP

maximizing survival following SCA in the athletic setting.

may improve the potential for a successful outcome, particularly if the coach is the victim.

Intercollegiate Sports Detailed reports of resuscitation outcomes for National

Location of AEDs and Training of School and Athletic Staff

Collegiate Athletic Association athletes demonstrate

AEDs should be readily available and on site at the athletic

dismal survival rates. A report of National Collegiate

venue when emergency situations arise, ensuring no more

Athletic

of

than a 2- to 3-minute turnaround from the site of potential

Division I, 77% of Division II, and 81% of Division III

collapse. Schools should ensure that away competitions

institutions had at least one AED on site (120,121).

have protection or bring a spare AED. Certification in CPR,

Although an encouraging development, a comprehensive

AED, and EAP review should be required for all athletic

Association

programs

found

that

91%

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personnel associated with practices, competitions, skills

elements of secondary school curricula, with guidelines

instruction, and strength and conditioning.

for overcoming barriers (130).

Funding for School/Athletic Field AEDs

of teaching CPR and AED use to school children. Such

Many funding sources are available, including donations

training should emphasize the recognition of SCA, the

by community organizations, foundations, hospitals, and

importance of calling for help or for an AED, and the

individuals who have lost a family member. Once ob-

delivery of high-quality chest compressions. Studies in

tained, responder training, maintenance of pads, and

subjects aged 4 to 20 years indicate the improvements

replacement and maintenance of batteries results in

that occur with training. Those provided instruction in

additional operational costs.

practical, hands-on skills exhibit better performance skills

A number of studies support the feasibility and efficacy

than do those with instructional or theoretical knowledge AEDs in Schools

alone. Chest compression depth correlates with physical

It has been estimated that on any given school day, 20%

factors such as weight and height, with studies showing

of the population will be in a school, including many adult

that 14 year olds can perform these skills as well as can

employees, visitors and those using schools for commu-

adults (131). With minimal training, 9 to 12 year olds have

nity events, including adult education and voting.

been shown to accurately use an AED in a time frame just

In 2004, guidelines for treating SCA in schools sug-

slightly shorter than that expected of trained emergency

gested that a lay rescuer AED implementation program be

medical technicians. Training by school teachers has been

considered in any location (e.g. school) with at least one

shown to be as effective as that performed by healthcare

of the following: 1) a reasonable probability of AED use

professionals. The most effective retention training has

within 5 years after AED placement and training of lay

not been determined, but full instructor-led courses are

rescuers; 2) high-risk adults working at the school or

not more effective than self-instruction and computer-

children attending school who might be at risk for a SCA;

based models.

and 3) the inability to reliably achieve a EMS call-to-shock

In King County, WA, 52% of bystanders can perform

interval of 35 years old) athletes. The Think

whether identification of an underlying high-risk condi-

Tank organizers selected 4 critical multidisciplinary do-

tion is a meaningful outcome compared with a traditional

mains for which participants were charged with identi-

hard outcome such as SCA/SCD. These questions are

fying the most urgent gaps: 1) Quantifying risks to

similar to what we have faced with other forms of

American athletes; 2) Education, and optimal use of

asymptomatic disease, such as silent ischemia in CAD, or

existing clinical athlete care tools; 3) Research, quality,

functional class 1 (Class A) heart failure/ cardiomyopathy.

for

outcomes.

Experts

must

determine

and science; and 4) Advocacy and communications. Once

Once the metrics have been defined, prospective

gaps were determined, specific strategies and methods

athlete outcomes registries must be designed that are

were designed to close those gaps, responsibilities were

sports specific and level specific, and that take into ac-

assigned to specific stakeholders, and a time frame for

count athlete heterogeneity. If hard end-points occur at

implementation was created. The time frame was meant

low frequency in athletic populations, then softer cardiac

to convey the urgency of the issue as well as relative

end-points such as arrhythmias, cardiac consultations,

priorities of different recommendations.

hospitalizations, and need for cardiac procedures or treatments, as well as perhaps sports medicine end-

Quantifying Risks to American Athletes (Table 8)

points such as days off practice or out of competition

Owing to athletic cardiac adaptations, the demands of

should be considered as alternative end-points. Risks of

exercise, and the risks and benefits of vigorous exercise,

cardiac testing and treatments, and the risks of a

athletes are considered a distinct patient group, requiring

sedentary lifestyle should also be factored into the risk

tailored cardiovascular care and science devoted to their

equation.

unique needs (14,135,136). Regarding cardiac risks to athletes, Think Tank participants defined the most urgent

Education and Optimal Use of

gaps as the need for sports cardiology metrics, for high-

Existing Clinical Athlete Care Tools (Table 9)

quality epidemiologic research, and for education. True

Think Tank participants identified urgent gaps in knowl-

cardiovascular risks to athletes are not known because

edge of athlete cardiovascular care, conditions that place

large, prospective, longitudinal cohort studies have not

athletes at risk, and risk mitigation strategies such as

been conducted in young athletic populations with sus-

hands-only CPR, recognition of SCA and its warning signs,

pected low prevalence of disease, using well-defined,

and optimal implementation of AEDs in schools and

consensus-derived metrics. Retrospective studies of the

athletic venues. To address these gaps, Think Tank par-

incidence of SCA/SCD in athletic populations have deliv-

ticipants recommend immediate steps toward optimal use

ered variable results (42,44–46,75,76), perhaps owing to

of existing clinical tools through education and/or

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certification of providers making participation decisions

the most pressing and severe gaps in sports and exercise

(at all levels). Federal Department of Transportation cer-

cardiology. Areas of greatest immediate need are the un-

tification, recently required by providers signing off on

certain predictive value of symptoms; the lack of norma-

commercial driver Department of Transportation physical

tive data in large populations of American athletes of

examination forms (137), serves as a good model for cer-

varying age, gender, race, ethnicity, size, and sport; the

tification. Non-formal certifications can be issued through

lack of an evidence base for the traditional participation

professional societies as a simple certificate of proficiency

guidelines; and major evidence gaps in the ECG screening

in sports cardiology (for cardiologists), and/or perfor-

debate. The AHA screening guidelines are based on the

mance of PPEs (for primary care providers). Recom-

clinical presentation of underlying inherited diseases and

mended education includes knowledge and use of the 4th

the ability of providers to recognize and act upon these

PPE, 12 AHA elements, 36th Bethesda Conference guide-

diseases (16). Although many data have been derived

lines, and Masters Athlete’s guidelines. Enhanced pres-

from general populations, very little has been generated

ence of existing clinical guidelines on the websites of all

in athletic populations (14) and nothing prospectively.

national organizations and state chapters can immedi-

Therefore, we propose that the sports cardiology com-

ately increase awareness of these clinical tools, and

munity promote and conduct research that examines the

knowledge and use of tools can be monitored through

predictive value of symptoms in athletes, aligns data

performance improvement activities and continuing

among disparate groups, and develops data-driven man-

medical education.

agement algorithms. Importantly, the predictive value of

Beyond the promotion of existing clinical tools, Think

symptoms in athletes presenting to front-line providers

Tank participants encourage the development of core

may be vastly different from that of symptoms in athletes

competencies in sports and exercise cardiology and the

presenting to cardiologists.

inclusion of basic sports cardiology competencies, as

Most of the athlete ECG data have been generated in

appropriate to type of practice, in general certification

Europe, with very little generated in the United States.

exams for the following professional groups: cardiolo-

Inherited diseases vary in incidence according to age,

gists, sports physicians, primary care providers (pedia-

gender, and race and ethnicity; thus, it may not be

tricians

trainers,

appropriate to extrapolate data from Europe to the

physician assistants, nurse practitioners, school nurses,

United States. Moreover, sports such as American foot-

athletic directors, and coaching staff). The ACC Sports and

ball do not exist in Europe, so it is unlikely that European

Exercise Cardiology Section has recently outlined its

ECG and echocardiographic data would be applicable to

vision for sports cardiology in the United States (14) and is

this group. Normative data in American football need to

in the process of developing core competencies for both

be reviewed and norms defined for practical application.

adult and pediatric cardiologists.

The same is true for cardiac magnetic resonance imaging,

and

family

practitioners,

athletic

At the local level, athlete cardiovascular care lends

computed tomography, ambulatory monitoring, and

itself particularly well to team-based approaches, which

cardiopulmonary stress testing. Knowledge gaps can

provide the athlete with the expertise of all those with a

potentially be closed through research evaluation of

stake in athlete cardiovascular care across the contin-

large numbers of American athletes (level and sports

uum. Gaps at multiple levels in knowledge of risk

specific).

mitigation strategies—such as hands-only CPR, recogni-

Once the value of symptoms and normative data for

tion of SCA and its warning signs, optimal implementa-

cardiac testing has been described, data-driven man-

tion of AEDs in schools and athletic venues—are probably

agement algorithms can be designed. Although man-

Advocacy

agement algorithms have been developed for relatively

section). But a national coalition of professional organi-

healthy athletes, those with congenital, genetic or ac-

zations can create an educational tool kit that can be

quired cardiac disease who wish to participate in ath-

used by all 50 states to educate all stakeholders and

letics (competitive or recreational) have special needs

providers about primary and secondary prevention

that have not been well addressed in the past. Although

strategies. Creation and distribution of public service

there have been guidelines (15) addressing participation

announcements at sporting events can promote hands-

eligibility, a great number of adult patients choose,

only CPR and early application of the AED. Legislation

with informed consent, to participate in activities that

in all 50 states should be considered (see Advocacy

some professionals feel are too dangerous. The concept

section).

of informed consent and overall quality of life issues

best

addressed

at

the

state

level

(see

for the athlete should be taken into account when Research, Quality, and Science (Table 10)

drafting such future guidelines; however, fully informed

Think Tank participants recognized that the need for

consent implies there are some risk data to present to

rigorous research and meaningful data represented one of

the athlete with disease who hopes to participate. To

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Protecting the Heart of the American Athlete

fully inform the athlete, much like when patients are

school nurses be trained in CPR and AED use; that each

counselled regarding the risk of aortic valve surgery

school develop an Emergency Action Plan (EAP); that

or heart transplant, an estimate of risk must be pre-

details of any SCA/SCD event be entered into a common

sented. This cannot be done without research-based

registry; that all student-athletes and their parents/

registries that include those with disease. The implant-

guardians be educated regarding the signs/symptoms of

able cardioverter defibrillator registry is a start, but

SCA/SCD; and that all grade 7-12 school students have the

similar studies must be considered in all those with

opportunity to be trained in SCA/SCD, CPR, and AEDs.

disease who wish to participate. Other sports cardiology

There is some evidence that state-based advocacy efforts

research priorities have been outlined in a recent paper

have been fruitful (21,24,126–128).

from the ACC Sports and Exercise Cardiology Section

It is important to appreciate that each state must evaluate the needs of its community and work closely

(Table 11) (14).

with professional organizations (participants in producAdvocacy and Communications (Table 12)

ing this document), to determine the appropriateness of

Think Tank participants determined that the most crucial

legislative initiatives on a state-by-state basis. Examples

gaps in the United States included a lack of coordinated

of successful use of legislative initiatives include at least

advocacy efforts that have the support of all stakeholders

1 piece of AED legislation in all 50 states (138) as well as

and that controversies regarding screening prevent

expansion of Good Samaritan legislation in other states.

screening standardization throughout the United States,

On the federal level, the reality of legislative initiatives

resulting in inconsistent messaging from American pro-

does not seem as easy to achieve. The rural AED act has

fessional groups. To close these gaps, Think Tank partic-

received some funding in the past, but it remains a

ipants propose the creation of a coalition of national

battle to maintain funding levels. Although there are

American professional groups working in collaboration,

currently bills in the House and Senate that will provide

who would meet every 2 years to create uniform

both education on creating EAPs for schools in the event

standards and present a consistent, unified message to

of a cardiac emergency and SCA risk assessment tools to

providers. Recognizing that such policies are best imple-

school age children (HEARTS Act [139]), these initiatives

mented on a state-by-state basis, the Think Tank also

are slow-moving and have lacked public awareness and

recommends the creation of state-wide athlete cardio-

support to aid their passage. In the private sector,

vascular care task forces.

various nonprofit entities are seeking to improve cardiac

Methods to improve student-athlete cardiovascular

assessments and prompt access to defibrillation. These

care can originate in both the public and private sectors,

private initiatives raise awareness and, although well

and from the grass roots to the federal level. Opportu-

meaning, may not fully address the needs of a particular

nities exist down to the local level in terms of ordinances

community owing to limited resources. Collaboration

and

departments,

and partnership between state and federal interests,

although these measures are laborious and tend to be

professional organizations, nonprofit organizations, and

highly variable in appearance. State level efforts seem to

patient advocacy organizations (all on state-by-state

be most realistic and attainable, as these models allow for

basis, outlined above) offer the best chance for mean-

efficient communication with all stakeholders and fit

ingful change in policy practice and, ultimately, outcome

logically into existing healthcare delivery systems. We

improvement in these areas.

policies

of

municipal

recreation

suggest that multidisciplinary state-wide task forces be

Think Tank participants felt we could do a better job

formed in all 50 states, consisting of representatives

at standardizing screening methods throughout the

from: state chapters of the National Athletic Trainers

United States. National professional societies and pro-

Association, AAP, AAFP, ACC, ACSM, AHA, school nurses

fessional organizations can improve efforts to define

association, physician assistants, state high school activ-

“standards” and their implementation by addressing is-

ities/athletics associations, Department of Health and

sues including: if we screen, who we screen, how and

Human Services, state boards of education, and medical

why we screen; RTP recommendations based on positive

examiners. The goals of each task force will vary from

AHA elements or test findings; and attempts to reduce or

state to state, but advocacy efforts can be focused on the

eliminate disparities in care. Consideration should be

following: setting standards as to who can perform the

given to collating all major athlete participation guide-

PPE; requiring the 4th PPE in all states; and requiring

lines (4th PPE, 36th Bethesda Conference, 12 AHA ele-

that providers performing PPEs or cardiac consultation

ments) into 1 guideline. This approach has merit because

be educated and/or certified in cardiac assessment of

a student athlete may be cleared by a primary care

adolescents; that every public and non-public school in

provider, with or without cardiology consultation. This

the state has 1 or more AEDs; that all coaches, licensed

will require coordination between all major professional

athletic trainers, athletic directors, administrators, and

societies with a stake in athlete care. Guidance can be

2165

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provided by a coalition of national professional societies,

done here: quantifying risk, education, optimal use of

but implementation on a state-by-state basis is recom-

existing tools, research, advocacy, and communica-

mended to achieve optimal distribution and effective-

tions. This would allow for a comprehensive approach,

ness. The coalition of national stakeholders, meeting on

less duplication of efforts, greater speed and efficiency,

a regular basis, can solve the problem of inconsistent messaging.

and optimal collaboration. 2. Commitment by the Think Tank participants to meet regularly to discuss athlete cardiovascular care issues

Individual Athlete Advocacy

and to disseminate Think Tank proceedings to their

Resources should be allocated to provide education ef-

respective organizations. Mini-think tanks with repre-

forts that ensure athletes know signs and symptoms as

sentatives from key organizations could meet regularly

well as how and to whom to report these concerns in a

to discuss a particular subject, such as metrics, and

manner they feel is safe and protects their confidentiality.

report their findings to the Think Tank annually or

In the context of community-based screening initiatives,

every other year.

effectiveness must be weighed against the risk of false

From our action plan, we have suggested the following

reassurance and communicated to participants. Whether

mini-think tanks or task forces would qualify as

screenings include history and physical alone or add ECGs or echocardiograms, the value added and the countervailing false positive/false negative rates should be reported to participants in clearly comprehensible language. The minor athlete requires special consideration. Choices made on behalf of a minor athlete by parents or

priorities (in order of urgency): a. Creating an athlete cardiovascular care task force in each state b. Promoting development of team-based care at local levels (athletic trainers, team physicians, school nurses, primary care providers, cardiologist and cardiac subspecialists)

guardians are of special concern. The athlete’s choice to

c. Developing evidence-based symptom management

participate may be overruled by parents, physicians, or

d. Defining normative data in American athletes: ECG,

the governing body of the sport. Special attention should

echocardiography, magnetic resonance imaging,

be paid to the emotional needs of this population.

computed

tomography,

ambulatory

monitoring,

Advocacy and awareness efforts using mass media are

stress testing; closing knowledge gaps through

critical tools for educating the general public regarding

research involving large numbers of American ath-

what they can and cannot expect from community-based screenings as opposed to full clinical evaluation by a cardiologist. Educational efforts addressing both the risks and the benefits to cardiac health presented by participation in (or lack of participation in) athletic endeavors, both organized and recreational, should be enhanced and

letes (age level and sports specific) e. Reviewing current sports cardiology metrics; proposing additional end-points f. Creating prospective athlete outcomes registries linked to specific metrics g. Optimizing

implementation

of

existing

clinical

communicated to the public. Encouragement for those

tools through enhanced education and/or informal

with risk factors to receive comprehensive cardiac eval-

certification of multiple and diverse providers; in-

uations should be addressed in a balanced manner in the

cludes knowledge and use of 4th PPE, 12 AHA ele-

media.

ments, 36th Bethesda guidelines, masters athletes guidelines

SECTION 5. SUMMARY AND NEXT STEPS The ACC Sports and Exercise Cardiology Think Tank was convened to define the current cardiovascular issues and needs of the American athlete and to develop an action plan to guide future cardiovascular care efforts. Participants felt strongly that, rather than occurring as an isolated event, our discussion should serve as the beginning of an on-going dialogue and collaboration between highly diverse stakeholders. Logical first steps are listed below. 1. Development of a directory of the multiple participating organizations, with a list of ongoing and planned activities in the domain of athlete cardiovascular safety. Activities could be classified as we have

h. Creating competencies for all those involved in athlete cardiovascular care that are appropriate to type of practice, in collaboration with respective professional societies and board examiners such as cardiologists, sports physicians, primary care physicians (pediatrics and family medicine), athletic trainers, physician assistants, advanced practice nurses,

school

nurses,

athletic

directors,

and

coaching staff i. Educating athletes and all front-line providers about warning signs and symptoms for early identification of SCA-related conditions, and about actual recognition of SCA occurrence j. Enhancing widespread availability of AEDs, developing EAPs, and promoting hands-only CPR

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Protecting the Heart of the American Athlete

Only through committed and focused collaboration can these

primary care and all its disciplines, sports medicine, and ath-

goals be achieved and the practical day-to-day cardiovascular

letic training. Our professional societies, funding agencies,

care of athletes be improved. For these efforts to be successful,

payers, and industry must be willing to invest in athlete car-

they must be conducted by multidisciplinary teams of medical

diovascular safety. It is hoped that these Think Tank pro-

and nonmedical scientists, with support from professional

ceedings will stimulate and support meaningful, continued

societies representing cardiology and its subspecialties

efforts in the future in this important area.

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APPENDIX 1. LISTING OF AUTHOR RELATIONSHIPS WITH INDUSTRY AND OTHER ENTITIES (COMPREHENSIVE)—PROTECTING THE HEART OF THE AMERICAN ATHLETE: PROCEEDINGS OF THE AMERICAN COLLEGE OF CARDIOLOGY SPORTS AND EXERCISE CARDIOLOGY THINK TANK

Committee Member Christine E. Lawless

Employment

Personal Research

Institutional, Organizational, or Other Financial Benefit

Expert Witness

None

None

None

None

None

None

Eisenhower Army Medical Center– Director, Military Sports Medicine

None

None

None

None

None

None

Irfan M. Asif

University of Tennessee Family and Sports Medicine—Assistant Professor; Fellowship Director, Sports Medicine

None

None

None

None

None

None

Ron Courson

University of Georgia— Senior Associate Athletic Director

None

None

None

None

None

None

Carolina Cardiology Consultants

None

None

None

None

None

None

Medstar Washington Hospital Center– Director, Cardiac MRI

None

None

None

None

None

None

None

None

Chad Asplund

Michael S. Emery Anthon R, Fuisz

Richard J. Kovacs

Sports Cardiology Consultants, President

Consultant

Ownership/ Speakers Partnership/ Bureau Principal

Krannert Institute of Cardiology– Professor of Clinical Medicine

 Biomedical Systems  Insight Pharmaceuticals  Theravance†  Xenoport

 Biotie  Cook (DSMB) Incorporated  Eli Lilly Med Institute† (DSMB)†

None

Silvana M. Lawrence

Baylor College of Medicine—Associate Professor, Department of Pediatrics, Section of Cardiology

None

None

None

None

None

Benjamin D. Levine

Institute for Exercise and Environmental Medicine

None

None

None

None

None

Mark S. Link

Tufts Medical Center

None

None

None

None

None

None

Matthew W. Martinez

Lehigh Valley Health Network

None

None

None

None

None

None

University of Virginia Health Sciences Center–Division Chief of Pediatric Cardiology

None

None

None

None

None

None

G. Paul Matherne

None

 Defendant, 2013, Postural Orthostatic Tachycardia Syndrome

Continued on the next page

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APPENDIX 1. CONTINUED

Committee Member

Employment

Brian Olshansky

William O. Roberts

University of Iowa Hospitals–Professor of Medicine

Consultant  Arrhythmia Grand Rounds*  BioControl  Boehringer Ingleheim  Boston Scientific (guidant)  Combined Medicare Medicaid Services  Daiichi Sankyo  Gerson Lehman  Medtronic†  Sanofi Aventis

Ownership/ Speakers Partnership/ Bureau Principal None

None

Personal Research

Institutional, Organizational, or Other Financial Benefit

 Amarin  Boston Scientific  (DSMB)  Executive  Boston Health  Scientific Resources† (DSMB)  Thompson  Sanofi Reuters* Aventis (DSMB)

Expert Witness Defendant, 2013 Event Monitors Third Party, 2012, Cardiac Arrest

University of Minnesota Medical School– Professor, Department of Family Medicine and Community Health

None

None

None

None

None

None

Hypertrophic Cardiomyopathy Association–Chief Executive Officer

None

None

None

None

None

None

Victoria L. Vetter

Children’s Hospital of Philadelphia Division of Cardiology– Professor of Pediatrics

None

None

None

None

None

None

Robert A. Vogel

University of Colorado–Professor of Medicine

None

None

None

None

Jim Whitehead

American College of Sports Medicine– Executive Vice President/Chief Executive Officer

Lisa Salberg

 Pritikin Longevity Center  National Football League†

 Sanoޠ

This table represents all relationships of committee members with industry and other entities that were reported by authors, including those not deemed to be relevant to this document, at the time this document was under development. The table does not necessarily reflect relationships with industry at the time of publication. A person is deemed to have a significant interest in a business if the interest represents ownership of $5% of the voting stock or share of the business entity, or ownership of $$10,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person’s gross income for the previous year. Relationships that exist with no financial benefit are also included for the purpose of transparency. Relationships in this table are modest unless otherwise noted. Please refer to http://www.cardiosource.org/Science-AndQuality/Practice-Guidelines-and-Quality-Standards/Relationships-With-Industry-Policy.aspx for definitions of disclosure categories or additional information about the ACC/AHA Disclosure Policy for Writing Committees. *No financial benefit. †Indicates significant relationship.

APPENDIX 2. ABBREVIATIONS AAFP ¼ American Academy of Family Physicians

EAP ¼ emergency action plan

AAP ¼ American Academy of Pediatrics

ECG ¼ electrocardiogram

ACC ¼ American College of Cardiology

EMS ¼ emergency medical services

ACSM ¼ American College of Sports Medicine AHA ¼ American Heart Association AED ¼ automated external defibrillator CAD ¼ coronary artery disease

FHX ¼ family history PPE ¼ Pre-participation evaluation PVC ¼ Premature ventricular contractions

CP ¼ chest pain

RTP ¼ return to play

CPR ¼ cardiopulmonary resuscitation

SCA ¼ sudden cardiac arrest

EAC ¼ exercise-associated collapse

SCD ¼ sudden cardiac death

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